American Hospital Association

The American Hospital Association (AHA) has again complained to the Centers for Medicare & Medicaid Services about “serious problems’’ with the hospital-compliance reviews by the Office of the Inspector General (OIG) of the Department of Health & Human Services.

AHA complained last week that the audits routinely include “fundamental flaws and inaccuracies, both in the OIG’s understanding and application of Medicare payment rules and in the procedures the OIG uses to conduct the audits.” The hospital trade organization asserted that this causes very overstated repayment demands, undermines hospitals’ reputations and steals time and resources from patient care.

The association added that the audits can lead to uneven and unfair application of Medicare payment rules. It notes that some hospitals aren’t audited and the appeals process operates inconsistently

Healthcare Dive noted that: “This is not a new issue for hospitals. In a June 2014 letter to then-HHS Secretary Kathleen Sebelius, the AHA called for an immediate halt to the audits, saying the OIG’s findings and estimated payments were incorrect and ‘entirely redundant.’ A recent uptick in penalties for alleged reimbursement fraud and abuse has galvanized hospitals to again press for audit reforms.

“AHA says OIG’s tendency to extrapolate its findings to all claims in an audit period is aggravating the problem of overall flawed reports.’’

The news service speculated: “The AHA may be hoping HHS scales back the review process altogether, which would not be particularly surprising with the pressure in President Donald Trump’s administration to roll back regulatory burden. Recently, the CMS said it will take a more targeted approach in some areas to finding and investigating Medicare fraud and improper payments. It will focus on providers whose claim error rates or unusual billing practices stand out compared to similar providers.’’

“But while hospitals call for reforms in the OIG compliance reviews, a recent Wall Street Journal report raised serious concerns about hospital safety. Reviewing hundreds of Joint Commission inspection reports, the Journal found about 350 hospitals that maintained accreditation in 2014 despite Medicare violations. More than a third of those had additional deviations in 2015 and 2016.’’

A new survey by the American Hospital Association and AVIA found that three out of four healthcare leaders linked digital innovation and their institutions’ long-term competitiveness.

The report listed these essential factors, among others: sufficient IT resources, a flexible budget cycle and dedicated funding pool.

“Successfully scaling innovation is a strategic imperative, and these survey results crack the code,” Eric Langshur, CEO and co-founder of AVIA, said. “We now know that top performers share traits that allow them to accelerate innovation 52 percent faster than average organizations, shortening time to impact by a full year.”

In a KPMG survey published earlier this year, healthcare chief information officers ranked EHR optimization and population health as top digital concerns. Following them were such concerns as virtual-technology enhancements and enterprise resource planning.

The American Hospital Association has forwarded some options to Congress to consider for regulatory relief for healthcare organizations.

Tom Nickels, the AHA’s executive vice president for government relations and public policy, told Congress that although the government has eased some rules, a huge burden on hospitals remains.

He wrote: “Indeed, the regulatory burden faced by hospitals is substantial and unsustainable. In addition to the sheer volume, the scope of changes required by the new regulations is beginning to outstrip the field’s ability to absorb them.

Here are a few highlights as summarized by FierceHealthcare:

“Offer an Anti-Kickback safe harbor and Stark exemption for clinical integration agreements and patient assistance, as these laws can hinder care coordination.

“Issue an enforcement moratorium on the ‘96-hour’ rule, which requires critical access hospitals to certify that a patient could reasonably be transferred or discharged within 96 hours.

Amid all the turbulence over the future of the Affordable Care Act, one facet continues unchanged: President Trump’s administration is penalizing more than half the nation’s hospitals for having too many patients return within a month.

Medicare is punishing 2,573 hospitals, just two dozen short of what it did last year under former President Obama, according to federal records released Aug. 2. Starting in October, the federal government will cut those hospitals’ payments by as much as 3 percent for a year.

Medicare docked all but 174 of those hospitals last year as well. The $564 million that the government projects to save also is roughly the same as it was last year under Obama.

High rates of readmissions have been a safety concern for decades, with one in five Medicare patients historically ending up back in the hospital within 30 days. In 2011, 3.3 million adults returned to the hospital, running up medical costs estimated at $41 billion, according to the federal Agency for Healthcare Research and Quality.

The penalties, which begin their sixth year in October, have coincided with a nationwide decrease in hospital repeat patients. Between 2007 and 2015, the frequency of readmissions for conditions targeted by Medicare dropped from 21.5 percent to 17.8 percent, with the majority of the decrease occurring shortly after the health law passed in 2010, according to a study last year in the New England Journal of Medicine conducted by Obama administration health-policy experts.

Some hospitals began giving impoverished patients free medications that they prescribe for their recovery, while others sent nurses to check up on patients seen as most likely to relapse in their homes. Readmissions dropped more quickly at hospitals potentially subject to the penalty than at other hospitals, another study found.

“The sum of the evidence really suggests that this program is helping people,” said Dr. Susannah Bernheim, the director of quality measurement at the Yale/Yale-New Haven Hospital Center for Outcomes Research and Evaluation, which measures readmission rates for Medicare.

But the pace of these reductions has been leveling off in the past few years, indicating that the penalties’ ability to induce improvements may be waning.

“Presumably, hospitals made substantial changes during the implementation period but could not sustain such a high rate of reductions in the long term,” the New England Journal article said.

An analysis by Bernheim’s group found no decrease in the overall rate of readmissions between 2012 and 2015, although small drops in the medical conditions targeted by the penalties continued.

“We have indeed reached the limits of what changes in how we deliver care will allow us to do,” said Nancy Foster, vice president for quality at the American Hospital Association. “We can’t prevent every readmission. It could be that there is further room for improvement, but we just don’t know what the technique is to make that happen.”

The Hospital Readmissions Reduction Program was created through a section of the ACA designed to use the purchasing power of Medicare to reward hospitals for higher quality. Those penalties, along with other ones aimed at improving hospital care, have been spared the partisan rancor over the law, and they would have continued under the GOP repeal proposals that stalled in Congress. But they have also been largely ignored.

Dr. Ashish Jha, a professor at the Harvard T.H. Chan School of Public Health, said the fight over abolishing the Affordable Care Act has drowned out talk about how to make the health care system more effective. “We’ve spent the last six months fighting about how we’re going to pay for health insurance, which is one part of the ACA,” he said. “There’s been almost no discussion of the underlying health care delivery system changes that the ACA ushered in, and that is more important in the long run to be discussing because that’s what’s going to determine the underlying costs and outcomes of the health system.”

The readmission penalties are intended to neutralize an unintended incentive in how Medicare pays hospitals that had profited from return patients. Medicare pays hospitals a lump sum for a patient’s stay based on the nature of the admission and other factors. Since hospitals generally are not paid extra if patients remain longer, they seek to discharge patients as soon as is medically feasible. If the patient ends up back in the hospital, it becomes a financial benefit as the hospital is paid for that second stay, filling a bed that would not have generated income if the patient had remained there continuously.

Because of how the readmission-penalty program was designed, it is not surprising that the new results are so similar to last year’s. As before, Medicare determined the penalties based on readmissions of the same six types of patients: those admitted for heart attacks, heart failure, pneumonia, chronic lung disease, hip or knee replacements or coronary artery bypass graft surgery. Hospitals were judged on patients discharged between July 2013 and June 2016. Because the government looks at a three-year period, two of those years were also examined in determining last year’s penalties.

This year, the average penalty will be 0.73 percent of each payment Medicare makes for a patient between Oct. 1 and Sept. 30, 2018, according to a Kaiser Health News analysis. That too was practically the same as last year. Forty-eight hospitals received the maximum punishment of a 3 percent reduction. Medicare did not release hospital-specific estimates for how much lost money these penalties would translate to.

More than 1,500 hospitals were exempted from penalties this year as required by law. Those include hospitals treating veterans, children and psychiatric patients. Critical access hospitals, which Medicare also pays differently because they are the only hospitals in their areas, were excluded. So were Maryland hospitals because Congress has given that state extra leeway in how it distributes Medicare money.

Of the 3,241 hospitals whose readmissions were evaluated, Medicare penalized four out of five, KHN’s analysis found. That is because the program’s methods are not very forgiving: A hospital can be penalized even if it has higher than expected readmission rates for only one of the six conditions that are targeted. Every non-excluded hospital in Delaware and West Virginia will have their reimbursements reduced. Ninety percent or more will be punished in Arizona, Connecticut, Florida, Kentucky, Massachusetts, Minnesota, New Jersey, New York and Virginia. Sixty percent or fewer will be penalized in Colorado, Kansas, Idaho, Montana, Oregon, South Dakota and Utah.

Since the readmission program’s structure is set by law, the administration cannot make major changes unilaterally, even if it wanted to.

Congress last year instructed Medicare to make one future alteration in response to complaints from safety-net hospitals and major academic medical centers.

They have objected that their patients tended to be lower income than other hospitals and were more likely to return to the hospital, sometimes because they didn’t have a primary care doctor and other times because they could not afford the right medication or diet. Those hospitals argued that this was a disadvantage for them since Medicare bases its readmission targets on industry-wide trends and that it hurt them financially, depriving them of resources they could use to help those same patients.

Bernheim noted that despite those complaints, safety-net hospitals have shown some of the greatest drops in readmission rates. In October 2018, Medicare will begin basing the penalties on how hospitals compared to their peer groups with similar numbers of poor patients. Akin Demehin, director of policy at the hospital association, said, “We expect the adjustment will provide some relief for safety-net hospitals.”

Medicare is planning to release two other rounds of recurring quality incentives for hospitals later this year. One gives out bonuses and penalties based on a mix of measures, with Medicare redistributing $1.9 billion based on how hospitals perform and improve. The other, the Hospital-Acquired Condition Reduction Program, cuts payments to roughly 750 hospitals with the highest rates of infections and other patient injuries by 1 percent.

The Centers for Medicare & Medicaid Services has proposed deep cuts to how much it reimburses many hospitals to buy drugs.

The proposal would change the rate paid to hospitals for drugs under the 340B program. The program gives hospitals that serve many low-income patients access to deep discounts on some pharmaceuticals. The new proposal would significantly cut the payments that hospitals that serve many such patients receive for those medications.

Michael Newshel, an Evercore ISI analyst, told clients: “Medicare would essentially be clawing back most of the discount from hospitals, (without any impact to payment made to drug manufacturers).”

Mr. Newshel said that while the proposal would affect about half of all U.S. hospitals, such for-profit chains as Tenet Healthcare Corp. and HCA Healthcare Inc. wouldn’t feel any impact, because they don’t qualify for the discount program.

Tom Nickels, executive vice president of the American Hospital Association, said “It is unclear why the administration would choose to punitively target 340B safety-net hospitals serving vulnerable patients, including those in rural areas, rather than addressing the real issue: the skyrocketing cost of pharmaceuticals.”

Leaders of the hospital sector and other major healthcare groups have denounced the Senate Republican leadership’s Affordable Care Act repeal bill as little or no improvement over the House bill, which providers have criticized as imperiling the health of millions of patients.

Rick Pollack, president and CEO of the American Hospital Association, said of the”Better Care Reconciliation Act of 2017”:

“Unfortunately, the draft bill under discussion in the Senate moves in the opposite direction {from protecting coverage}, particularly for our most vulnerable patients. We urge the Senate to go back to the drawing board and develop legislation that continues to provide coverage to all Americans who currently have it.”

Bruce Siegel, M.D., president and CEO of America’s Essential Hospitals, said: “For the hospitals that protect millions of Americans and their communities—our essential hospitals—this bill might even accelerate decisions by some to reduce services or close their doors.”

“The Senate healthcare bill released today is just as bad as the version passed by the House of Representatives last month and is a threat to the health of America,” said George Benjamin, M.D., executive director of the American Public Health Association. He asserted that Senate Republicans had committed “legislative malpractice.”

David O. Barbe, M.D., president of the American Medical Association, chimed in with:

“The AMA is reviewing the Senate health system reform legislation, guided by our key objectives that people who are currently insured should not lose their coverage and that Medicaid, CHIP and other safety-net programs should be adequately funded. The AMA strongly opposes Medicaid spending caps, and we have grave concern with a formula that will not cover needed care for vulnerable patients.”

And Bernard J. Tyson, chairman and CEO of Kaiser Permanente, said: “First, we need to cover more people, not fewer people.” He suggested a three-part test to determine what healthcare progress ought to look like: Does it achieve wider access, affordability and better outcomes?

“I appreciate the work of the Senate as they continue to make progress fixing the crisis in healthcare that has resulted from Obamacare. Skyrocketing premiums, rising costs and fewer choices have caused too many Americans to drop their insurance coverage. Today, Obamacare is in a death spiral and millions of Americans are being negatively impacted as a result. They are trapped by mandates that force them to purchase insurance they don’t want and can’t afford.” {The term “Obamacare” is usually used by Republicans as a derogatory term for the Affordable Care Act, the law’s official name.}

“The Senate proposal is built on putting patients first and in charge of their healthcare decisions, bringing down the cost of coverage and expanding choices. Congress must act now to achieve the president’s goal to make sure all Americans have access to quality, affordable coverage.”

Marion Mass, M.D., wrote a piece for The Philadelphia Inquirer headlined “A doctor’s perspective: Who stands for patients in the healthcare debate?” Among her observations:

“Take a look at the top lobbyist groups in America. Four are health-care related: Big insurance, Big Pharma, the American Hospital Association and the American Medical Association.

“The result of this lobbying is a phenomenon that can be summed up in two words: administrative glut.

“Since 1970, the number of physicians practicing in America has grown by roughly 200 percent. By contrast, the percentage growth of administrators in the same time period is over 3,000 percent. Healthcare spending per capita has grown by 2,300 percent over the same time period. ”

“The American people are the victims of a {healthcare} system so complex that even many practicing physicians have a hard time unraveling it. But they are certain that their patients’ needs are suffering. Your physician, the one delivering or caring for your children, the one who guides you through your twilight years, has little voice and less confidence in this establishment, mirroring the feelings of frustrated Americans

“There is hope.

“Dozens of grassroots physician groups are working for real reform. We are aligned together and actively collaborating, to find real solutions to heal our sick system. United, we have a stronger voice to advocate for our patients. We see your suffering. It’s personal for us, because medicine is personal. You learn that the first time you interview a patient and lay your hands on them for examination.

“We believe reducing administrative glut and creating more choices of coverage are the two main components to increase quality access to care and reduce cost for all. The Health Rosetta Principles, formulated as a collaborative effort among entrepreneurs and visionaries in the healthcare space, covers the basic tenants of our proposed changes. A specific, patient-centric representative plan has been developed by the Docs4Patient Care Foundation.”

The federal government has cut payments to 769 hospitals with high rates of patient injuries, for the first time counting the spread of antibiotic-resistant germs in assessing penalties.

The punishments come in the third year of Medicare penalties for hospitals with patients most frequently suffering from potentially avoidable complications, including various types of infections, blood clots, bed sores and falls. This year the government also examined the prevalence of two types of bacteria impervious to drugs.

Based on rates of all these complications, the hospitals identified by federal officials this week will lose 1 percent of all Medicare payments for a year — with that time frame beginning this past October. While the government did not release the dollar amount of the penalties, they will exceed a million dollars for many larger hospitals. In total, hospitals will lose about $430 million, 18 percent more than they lost last year, according to an estimate from the Association of American Medical Colleges.

The reductions apply not only to patient stays but also will reduce the amount of money hospitals get to teach medical residents and care for low-income people.

Forty percent of the hospitals penalized this year escaped punishment in the first two years of the program, a Kaiser Health News analysis shows. Those 306 hospitals include the University of Miami Hospital in Florida, Cambridge Health Alliance in Massachusetts, the University of Michigan Health System in Ann Arbor and Mount Sinai Hospital in New York City.

Nationally, hospital-acquired conditions declined by 21 percent between 2010 and 2015, according to the federal Agency for Healthcare Research and Quality, or AHRQ. The biggest reductions were for bad reactions to medicines, catheter infections and post-surgical blood clots.

Still, hospital harm remains a threat. AHRQ estimates there were 3.8 million hospital injuries last year, which translates to 115 injuries during every 1,000 patient hospital stays during that period.

Each year, at least 2 million people become infected with bacteria that are resistant to antibiotics, including nearly a quarter million cases in hospitals. The Centers for Disease Control and Prevention estimates 23,000 people die from them.

Infection experts fear that soon patients may face new strains of germs that are resistant to all existing antibiotics. Between 20 and 50 percent of all antibiotics prescribed in hospitals are either not needed or inappropriate, studies have found. Their proliferation — inside the hospital, in doctor’s prescriptions and in farm animals sold for food — have hastened new strains of bacteria that are resistant to many drugs.

One resistant bacteria that Medicare included into its formula for determining financial penalties for hospitals is methicillin-resistant Staphylococcus aureus, or MRSA, which can cause pneumonia and bloodstream and skin infections. MRSA is prevalent outside of hospitals and sometimes people with it show no signs of disease. But these people can bring the germ into a hospital, where it can be spread by healthcare providers and be especially dangerous for older or sick patients whose immune system cannot fight the infection.

The second bacteria measured for the penalties is Clostridium difficile, known as C. diff, a germ that can multiply in the gut and colon when patients take some antibiotics to kill off other germs. It can also spread through contaminated surfaces or hands.

While it can be treated by antibiotics, C. diff can also become so serious that some patients need to have part of their intestines surgically removed. C. diff can cause diarrhea and can be deadly for the elderly and other vulnerable patients.

C. diff has challenged infection control efforts. While hospital infections dropped 8 percent from 2008 to 2014, there was a “significant increase” in C. diff that final year, the CDC says. AHRQ estimated there were 100,000 hospital cases last year.

“The reality is we don’t know how to prevent all these infections,” said Louise Dembry, M.D., a professor at the Yale School of Medicine and president of the Society for Healthcare Epidemiology of America.

The Hospital-Acquired Condition Reduction Program also factors in rates of infections from hysterectomies, colon surgeries, urinary tract catheters and central line tubs. Those infections carry the most weight in determining penalties, but the formula also takes into account the frequency of bed sores, hip fractures, blood clots and four other complications.

Specialized hospitals, such as those that treat psychiatric patients, veterans and children, are exempted from the penalties, as are hospitals with the “critical access” designation for being the only provider in an area. Of the remaining hospitals, the Affordable Care Act requires that Medicare penalize the 25 percent that perform the worst on these measures, even if they have reduced infection rates from previous years.

That inflexible quota is one objection the hospital industry has with the penalties. In addition, many hospitals complain that they are penalized because of their vigilance in detecting infections, even ones that do not cause any symptoms in patients. Academic medical centers in particular have been frequently punished.

“The HAC penalty payment program is regarded as rather arbitrary, so other than people getting upset when they incur a penalty, it is not in and of itself changing behavior,” said Nancy Foster, vice president for quality and patient safety at the American Hospital Association.

Federal records show that 347 hospitals penalized last year will not have payments reduced because their performance was better than others. Those include Harbor-UCLA Medical Center in Los Angeles, the Johns Hopkins Hospital in Baltimore and the University of Tennessee Medical Center in Knoxville.

Over the lifetime of the penalty program, 241 hospitals have been punished in all three years, including the Cleveland Clinic; Intermountain Medical Center in Murray, Utah; Ronald Reagan UCLA Medical Center in Los Angeles; Grady Memorial Hospital in Atlanta; Northwestern Memorial Hospital in Chicago; and Brigham & Women’s Hospital in Boston.

The penalties come as the Centers for Medicare & Medicaid Services also launches new requirements for hospitals to ensure that the use of antibiotics is limited to cases where they are necessary and be circumspect in determining which of the drugs are most likely to work for a given infection. Hospitals will have to establish these antibiotic stewardship programs as a condition of receiving Medicare funding under a regulation the government drafted last summer.

Lisa McGiffert, who directs Consumers Union’s Safe Patient Project, said that as a result of Medicare’s penalties and other efforts, “more hospitals are thinking more about appropriate use of antibiotics.” However, she said, “I think most hospitals do not have effective antibiotic stewardship programs yet.”

Becker’s Hospital Review has done a handy 10 things to know about CMS’s final rule on a mandatory bundled-payment program for coronary-artery-bypass surgery and its expansion of the existing Comprehensive Care for Joint Replacement program. To read whole article, please hit this link.

Here they are, stripped down:

1. “Under the final rule, acute care hospitals in certain markets will be accountable for the cost and quality of care provided to heart attack, coronary bypass and surgical hip and femur fracture patients beginning with hospitalization and extending 90 days after discharge.”

3. “Hospitals will receive retrospective episode-based payments under the new bundles. Hospitals that spend less than the target price for the episode of care while meeting or exceeding quality standards keep the savings achieved. A hospital is required to repay Medicare if the costs exceed the target price.”

4. “The final rule includes a cardiac rehabilitation payment model, which will test whether a payment incentive can increase the utilization of cardiac rehabilitative services….”

9. ”The American Hospital Association said it was pleased with some parts of the final rule, including the flexibility the rule provides regarding MACRA participation. However, the AHA expressed concern about the pace of change. ‘The bundled payment model for cardiac care is the second mandatory demonstration project the agency has finalized in just the past 15 months,’ said the AHA. ‘This is too much, too soon.”‘

At age 88, Elizabeth Fee looked pregnant, her belly swollen after days of intestinal ailments and nausea. A nurse heard a scream from Fee’s room in a nursing home, and found her retching “like a faucet” before she passed out.

The facility where she died in 2012 was affiliated with a respected San Francisco hospital, California Pacific Medical Center, and shared its name. Fee had just undergone hip surgery at the hospital, and her family, pleased with her care, said they chose the nursing home with the hospital’s encouragement.

Laura Rees, Fee’s elder daughter, said she was never told that the nursing home had received Medicare’s worst rating for quality — one star. Nor, she said, was she told that state inspectors had repeatedly cited the facility for substandard care, including delayed responses to calls for aid, disrespectful behavior toward patients and displaying insufficient interest in patients’ pain.

“They handed me a piece of paper with a list of the different facilities on it, and theirs were at top of the page,” Rees said in an interview. “They kept pointing to their facility, and I was relying on their expertise and, of course, the reputation of the hospital.”

Fee had an obstructed bowel, and state investigators faulted the home for several lapses in her care related to her death, including giving her inappropriate medications. In court papers defending a lawsuit by Fee’s family, the medical center said the nursing home’s care was diligent. The center declined to discuss the case for this story.

The selection of a nursing home can be critical: 39 percent of facilities have been cited by health inspectors over the past three years for harming a patient or operating in such a way that injuries are likely, government records show.

Yet many case managers at hospitals do not share objective information or their own knowledge about nursing home quality. Some even push their own facilities over comparable or better alternatives.

“Generally hospitals don’t tell patients or their families much about any kind of patterns of neglect or abuse,” said Michael Connors, who works at California Advocates for Nursing Home Reform, a nonprofit in San Francisco. “Even the worst nursing homes are nearly full because hospitals keep sending patients to them.”

Hospitals say their recalcitrance is due to fear about violating a government decree that hospitals may not “specify or otherwise limit” a patient’s choice of facilities. But that rule does not prohibit hospitals from sharing information about quality, and a handful of health systems, such as Partners HealthCare in Massachusetts, have created networks of preferred, higher-quality nursing homes while still giving patients all alternatives.

Such efforts to help patients are rare, said Vincent Mor, a professor of health services, policy and practice at the Brown University School of Public Health in Providence. He said that when his researchers visited 16 hospitals around the country last year, they found that only four gave any quality information to patients selecting a nursing home.

“They’re giving them a laminated piece of paper” with the names of nearby nursing facilities, Mor said. For quality information, he said, “they will say, ‘Well, maybe you can go to a website,’” such as Nursing Home Compare, where Medicare publishes its quality assessments.

The federal government may change this hands-off approach by requiring hospitals to provide guidance and quality data to patients while still respecting a patient’s preferences. The rule would apply to information not only about nursing homes but also about home health agencies, rehabilitation hospitals and other facilities and services that patients may need after a hospital stay.

“It has a substantial opportunity to make a difference for patients,” said Nancy Foster, a vice president at the American Hospital Association.

But the rule does not spell out what information the hospitals must share, and it has yet to be finalized — more than a year after Medicare proposed it. The rule faces resistance in Congress: The chairman of the House Freedom Caucus, Rep. Mark Meadows, R-N.C., has included it on a list of regulations Republicans should block early next year.

The government has created other incentives for hospitals to make sure their patient placements are good. For instance, Medicare cuts payments to hospitals when too many discharged patients return within a month.

“Hospitals didn’t use to care that much,” said David Grabowski, a professor of healthcare policy at Harvard Medical School. “They just wanted to get patients out. Now there’s a whole set of payment systems that reward hospitals for good discharges.”

But sometimes hospitals go too far in pushing patients toward their own nursing homes. In 2013, for instance, regulators faulted a Wisconsin hospital for not disclosing its ties when it referred patients to its own nursing home, which Medicare rated below average. In 2014, a family member told inspectors that a Massachusetts hospital had “steered and railroaded” her into sending a relative to a nursing home owned by the same health system.

Researchers have found that hospital-owned homes are often superior to independent ones. Still, a third of nursing homes owned by hospitals in cities with multiple facilities had lower federal quality ratings than at least one competitor, according to a Kaiser Health News analysis.

The Lowest Rating
But state inspectors found shortcomings in seven visits to the nursing home between August 2009 and October 2011, records show. Inspectors found expired medications during two visits and, at another, observed a nurse washing only her fingertips after putting an IV in a patient with a communicable infection. Medicare’s Nursing Home Compare gave the nursing home where Elizabeth Fee died one star out of five, meaning it was rated “much below average.” The hospital’s case managers told Fee’s family that the nursing home was merely an extension of the hospital and that “my mother would receive the same excellent quality of care and attention,” said Rees, her daughter.

Just four months before Fee arrived, inspectors cited the nursing home for not treating patients with dignity and respect and for failing to provide the best care. One patient told inspectors that her pain was so excruciating that she couldn’t sleep but that nurses and the doctor did not check to see whether her pain medications were working.

“Nobody listens to me,” the patient said. “I was born Catholic, and I know it’s not right to ask to die, but I want to die just to get rid of the pain.”

Fee ate little and had few bowel movements, according to the state health investigation. Fee’s family had hired a private nurse, Angela Cullen, to sit with her. Cullen became increasingly worried about Fee’s distended belly, according to Cullen’s affidavit taken as part of the lawsuit. She said her concerns were brushed off, with one nurse declining to check Fee’s abdomen by saying, “I do not have a stethoscope.”

On the morning of her death, an X-ray indicated Fee might have a bowel obstruction or other problem expelling stool, the inspectors’ report said. That evening, after throwing up a large quantity of matter that smelled of feces, she lost consciousness. She died of too much fluid and inhaled fecal matter in her lungs, the report said.

Bills Of More Than $150,000
Sutter Health, the nonprofit that owns the medical center and the nursing home, emphasized in court papers that Elizabeth Fee arrived at the facility with a low count of platelets that clot blood. Sutter’s expert witness argued that the near-daily visits from a physician that Fee received “far exceeds” what is expected in nursing home care.In a court ruling, Judge Ernest Goldsmith of the San Francisco Superior Court wrote that Nancy Fee’s younger daughter, Nancy, “observed her mother drown in what appeared to be her own excrement.” Kathryn Meadows, the family’s attorney, said in a court filing that the nursing home’s bills exceeded $150,000 for the three-week stay.

The physician and his medical group have settled their part of the case and declined to comment or discuss the terms; the case against Sutter is pending. California’s public health department fined Sutter $2,000 for the violations, including for delaying 16 hours in telling the physician about Fee’s nausea, vomiting and swollen abdomen. Last year, Sutter closed the nursing home.

A week or so after Fee died, a letter addressed to her from California Pacific Medical Center arrived at her house. It read: “We would appreciate hearing about your level of satisfaction with the care you received on our Skilled Nursing Rehabilitation Unit, the unit from which you were just discharged.”